Wound treatment

• Erosion: Superficial intraepidermal tissue defect
• Excoriation: tissue defect with injury to the papillary body
• Ulcer: Deep tissue defect with extension at least into the corium.

Wound: Separation of the tissue connection on external or internal body surfaces with or without tissue loss. A wound is said to be chronic if it has been present for more than 2-3 weeks.

Infected chronic wounds: signs of infection such as redness, swelling, fever, pain, increased secretion, foul odor are signs of wound infection. But: Every chronic wound is bacterially contaminated! An infection should always be treated with systemic antibiotics. The sensitivity of the germs can be determined by an antibiogram. Antiseptics should only be used for heavily bacterially contaminated wounds and for clinically manifest wound infection for no longer than 2-6 days. Prolonged use inhibits wound healing (cytotoxicity, granulation inhibition). In the long term, physiological saline solution is recommended for cleaning or other treatment of the wound (e.g. to remove dressing residues).

Remember! Local application of antibiotics to chronic wounds is obsolete!

Local application of antibiotics poses the risk of developing polyvalent contact allergies, the development of resistance and thus a significant disruption to wound healing. Furthermore, the assessment of the healing process is made more difficult by an increasing secretion of the "sensitized wound". Dyes and organic mercury compounds are also not indicated for wound treatment today.

Remember! Dyes are locally intolerable and insufficiently effective. Mercury compounds lead to sensitization and have systemic side effects! Hydrogen peroxide is considered dispensable as it has a cyotoxic effect, inhibits fibroblasts and can lead to necrosis.

Antiseptics are recommended:

Polihexanide ( Lavasept): due to its good tissue compatibility, the agent of choice for chronic or sensitive wounds, onset of action after 5 to 20 minutes.

Octenidine dihydrochloride ( Octenisept): Effective after 30 seconds to >5 minutes, also shows good tissue compatibility.

Polyvidon iodine (Betaisodona, Braunovidon): rapid onset of action within 30 seconds, which lasts as long as the presence of iodine is indicated by brown coloration. For chronic wounds, the manufacturer recommends a dilution of 1:2 to 1:20 with Ringer's solution or physiological saline solution.

Debridement: Removal of non-vital tissue from a wound. It should be the first step in the phase-oriented treatment of chronic wounds (see below). Wound debridement).

Wound dressings:

• Polyacrylates (see below gels, hydrophilic): They belong to the group of synthetic wound dressings. It is a cushion-shaped wound dressing that contains a so-called superabsorber made of polyacrylate. The superabsorbent is activated with Ringer's solution, which is continuously released into the wound and simultaneously absorbs secretions. This results in an absorbent rinsing effect with a very good cleansing effect. Examples include TenderWet 24 and TenderWet Duo.
• Hydrogels: Hydrogels consist of carboxymethyl cellulose, pectin, propylene glycol and, depending on the product, have a water content of up to 60% and can be combined with calcium alginate. Their high water content makes them suitable for dissolving fibrinous, necrotic, dry coatings and for rehydrating wounds.

  Note: hydrogels carry the risk of wound edge maceration

  ; examples include NU Hydrogel with alginate, Varihesive Hydrogel, Suprasorb G Amorphous Gel Intrasite Gel Comfeel Gel.
• Alginates: Alginates are mainly used in the cleansing phase and for moderate to heavy wound secretion. They are commercially available as compresses and tamponades. Alginates consist of salts of alginic acid, which are obtained from brown algae. Due to their swelling properties, they are suitable for wound cleansing. On contact with the wound secretion, insoluble calcium alginate is converted into soluble sodium alginate by exchanging the calcium ions for the sodium ions present in the blood and wound secretion. This leads to swelling and the formation of a gel that fills the wound and ensures a moist wound environment. This ion exchange also has a hemostyptic effect. Alginates can bind up to 20 times their own weight in secretion. Examples: Kaltostat, Sorbsan calcium alginate, Sorbalgon, Algosteril, Suprasorb A.
• Hydrofibre dressings: These can be used up to the epithelialization phase, consist of sodium carboxymethylcellulose and are commercially available as compresses and tamponades. They offer high absorbency (30 g secretion/g hydrofiber), wound secretion is only absorbed vertically and not horizontally. When applied overlapping the wound edge, they are therefore very suitable as wound edge protection in macerated and eczematized wound environments. They are ideal for use in cases of polyvalent contact allergy. For dry wounds, additional moistening with physiological saline solution or Ringer's solution is recommended. Examples include Aquacel, Aquacel Ag, Textus multi.
• Wound dressings containing silver: Ionic silver has recently regained importance in wound treatment due to its broad spectrum of antimicrobial activity. It works primarily by interfering with DNA synthesis and binding to structural and functional proteins of the bacterial cell. In contrast to other antiseptic substances, silver has a very low toxicity. Various material combinations with silver ions or nanocrystalline silver are available. The use of wound dressings containing silver is mainly indicated for infected and heavily bacterially contaminated wounds (Actisorb silver contains activated carbon fibers with silver impregnation; activated carbon absorbs bacteria, secretions, detritus and odor; silver has a bactericidal effect; Acticoat contains nanocrystalline silver which remains active for 3 days. It must be moistened with sterile distilled water in order to be activated. If saline solution is used, AgCl is formed and the silver ions are inactivated. If the dressing is too dry, silver precipitates will form on the wound. The blue side of the dressing must be placed on the wound. Acticoat can be left on the wound for up to 3 days, a secondary dressing is necessary.
• Foam and hydropolymer dressings: These can be used until the epithelialization phase. They consist of a polyurethane foam as a reservoir and a semi-permeable polyurethane surface with or without an adhesive edge. They are structurally stable, non-dissolving dressings that swell on contact with secretions. The dressing is also changed depending on the secretion behavior of the wound. In addition to absorbing exudate and cell detritus, a pressure and suction effect is also exerted on the wound bed, which promotes granulation. Products without an adhesive edge are suitable for tamponade of wound cavities, in unstable wound environments or for temporary defect coverage of surgical wounds. Examples include Tielle (sacrum, plus, borderless, lite), Allevyn (non-adhesive, adhesive with adhesive border, heel heel dressing, sacrum, cavity), PermaFoam, Contreet foam Ag (adhesive, non-adhesive), Suprasorb P, Mepilex (border).
• Hydrocolloids: They can be used up to the epithelialization phase. These are semi-occlusive wound dressings based on pectins, gelatine and cellulose derivatives. Hydrophilic colloidal particles are inserted into a hydrophobic polymer scaffold, above which is a semi-permeable (impermeable to liquids and germs, permeable to gases) polyurethane surface. The hydrophilic particles swell to form a gel on contact with secretions, resulting in a loss of adhesion to the wound surface. This can be recognized clinically as blister formation. In this moist wound environment, fibroblasts and macrophages are activated and growth factors are expressed, thereby promoting angiogenesis and keratinocyte proliferation. Where there is no contact with wound secretions, the dressing sticks to the skin. The wound environment should therefore be stable, i.e. free from irritation and eczema. For special localizations such as the heel or sacral area, there is an additional fixation edge for better adhesion. Depending on wound secretion, hydrocolloids can remain on the wound for several days up to a maximum of one week; they should not be applied to infected wounds. A gel forms under the hydrocolloid dressing, which must be removed with Ringer's solution or physiological saline solution when the dressing is changed. Any maceration of the wound edge by the gel can be minimized by combining it with a hydrofibre dressing. Examples include Suprasorb H (standard, thin, border, sacrum), Varihesive E (border, extra-thin), Hydrocoll (concave, sacral, thin). Combination products include Contreet H (hydrocolloid dressing with silver ions, which are released during the swelling process); CombiDerm (hydrocolloid with superabsorbent wound pad); Comfeel plus (hydrocolloid dressing with calcium alginate).
• Protease-regulating wound dressings: These consist of a freeze-dried matrix of bovine collagen and oxidized, regenerated cellulose. They are used for stagnant wounds in the granulation phase without fibrin coating up to the epithelialization phase. Proteases (matrix metalloproteinases, elastases, plasmin) are present in excess in chronic wounds and inhibit or inactivate growth factors. Due to the large surface area of this matrix, proteases are bound and inactivated, endogenous growth factors are bound and thus protected. These growth factors are released again in their active form when the matrix is resorbed. Free radicals are bound and cell proliferation is promoted. The matrix also has a hemostatic effect and ensures a moist wound environment; it can be used in combination with hydrocolloids and films. Example: Promogran.
• Biodegradable calf collagen: This is commercially available as a sponge structure and can be used for stagnant wounds in the granulation phase. Exudate, detritus and proteases are bound, thereby promoting the migration and proliferation of fibroblasts and thus collagen synthesis and subsequently re-epithelialization. The sponge structure ensures a moist wound environment and can be combined with hydrocolloids. Examples include Suprasorb C.
• Vacuum Assisted Closure System (VAC): The VAC therapy unit is used to continue effective wound cleansing after sufficient surgical debridement and especially in the granulation phase. By applying continuous or intermittent negative pressure with the aid of a sponge, the wound area is reduced by wound retraction, granulation tissue regeneration and blood flow to the wound bed are promoted, wound secretions are removed and the bacterial count is reduced. The black polyurethane sponge is coarse-pored and dry and is used for heavily exuding and infectious wounds. The white polyvinyl alcohol sponge is fine-pored and hydrated, prevents tissue ingrowth and is particularly suitable for protecting tendons, nerves and blood vessels. The Minivac system is also suitable for outpatient use. It is used for 1-4 weeks; for the epithelialization phase, a different dressing system must be used or surgical coverage may be considered.
• Tissue engineering products (currently still experimental approaches): These actively intervene in wound healing and are produced from autogenous, allogenic or xenogenic cells. The prerequisite for use is a cleansed, infection-free wound. They are reserved for special indications only, as they are currently still very expensive. Examples of tissue engineering products currently available in Europe with ulcus cruris venosum approval are Epicel (keratinocyte autograft), Epidex (autologous keratinocytes from hair root cells), Laserskin Autograft (hyaluronic acid sheets seeded with autologous keratinocytes) and Bioseed-S (autologous keratinocytes suspended in fibrin glue).
• Growth factors: The clinical results from existing clinical studies are currently still not very satisfactory. The clinical use of growth factors is therefore reserved for special indications. The prerequisite for use is a clean and infection-free wound. The only preparation currently approved is Regranex-0.01% gel, which contains becaplermin, a recombinant human platelet-derived growth factor. It is approved for neuropathic and diabetic ulcers up to a maximum of 5 ^cm2. Example: Regranex-0.01% gel.
• Artificial skin based on shark cartilage: Two-layer matrix system consisting of bovine collagen and glycosaminoglycans. Glycosaminoglycans were obtained from shark cartilage, hence the name "sharkskin". In the meantime, fish cartilage from other types of fish from unusable fish catches is also used. Preparation: ^INTEGRA®
• Chitosan-containing wound dressings, due to their anti-inflammatory, antimicrobial properties for chronic, bacterial or mycotic wounds; e.g. Chitoderm Plus
• Wound edge protection: e.g. stick with disiloxane and acrylate copolymer, preparation: ^Cutimed® PROTECT applicator, ^Secura® applicator

For guidelines on wound treatment see Table 1, for promotion of wound healing see Table 2; see also pressure ulcers.

I. Erosion: Single disinfectant solution such as polyvidon-iodine solution(e.g. Betaisodona solution).

II. excoriation: As for erosion, cleaning and sterile covering if necessary. In case of signs of inflammation, especially with progressive signs of inflammation, swab and antibiotic treatment according to antibiogram.

III. ulcer: In chronic wounds, wound cleansing, debridement and exudation control are the three decisive factors. The older concept of phase- or stage-appropriate therapy is increasingly being abandoned today, as the cleansing phase, granulation phase and epithelialization often occur in parallel in the different wound areas.

1. Wound cleansing: cleansing of contaminated, infected, necrotic and also pre-treated wounds:

   • Superficial coatings can be dissolved by baths with the addition of quinolinol (e.g. Chinosol, R042 ), camomile, potassium permanganate or also with Ringer's solution. Disinfectants with good efficacy and low tissue toxicity are polihexanide (Serasept, Prontoderm, Prontosan) and octenidine (e.g. Octenisept). Many older wound disinfectants, in particular dyes such as gentian violet solution but also hydrogen peroxide, impair wound healing with only a minor disinfecting effect. Therefore do not use for wound treatment!

   • Periulcerous environment: Ointment residues in the ulcer environment are removed, for example, with vegetable oils such as olive oil (Oleum olivarum). Firmly adhering necroses can usually only be removed mechanically with a ring curette, a sharp spoon or with tweezers and scissors or a scalpel; in patients who are very sensitive to pain, local anesthesia or surface anesthesia, e.g. with EMLA cream, may be necessary. If necessary, enzymatic wound cleansing, e.g. with clostridiopeptidase (e.g. Iruxol N ointment), can be considered. Hydrogels, e.g. NuGel, which can be used to soften coatings and necroses in the granulation phase to promote healing, have also proved effective. In the case of accompanying eczema reactions (e.g. contact allergic genesis), initial therapy with topical glucocorticoids in vaseline bases, e.g. 0.25% prednicarbate (e.g. Dermatop fatty ointment), later blank care with largely indifferent bases (e.g. Vaselinum album) or previously epicutaneous-tested preparations. In addition, existing, e.g. iatrogenic dehydration eczema after intensive moisturizing treatment should also be treated with indifferent fatty ointments. In the case of heavily exudating wounds, it is advisable to cover the area around the wound to prevent irritation, e.g. with zinc paste (Pasta zinci DAB) or pure Vaselinum, and special wound dressings, e.g. calcium alginates, are also used. acrylate terpolymer film preparations offer good protection of the surrounding skin.

2. Exudate control: A variety of preparations are available (see Table 3).

   • Superficial ulcers: Hydrocolloid films (e.g. NuDerm) have proved effective for clean, non-secreting and superinfected ulcers. Wound dressings with limited fluid absorption capacity, such as hydrogels or films (e.g. Bioclusive, Cutifilm plus, Tegaderm) are also suitable for less exuding ulcers. Synthetic wound dressings are an effective microbial barrier and offer good mechanical and thermal protection. Dressing changes are generally painless and without trauma, so that they are well tolerated by patients (see also Table 4).

   • Deep ulcers: Gels (e.g. Intrasite Gel, Varihesive Hydrogel) or alginates (e.g. Trionic) are well suited to filling deep wounds and niches, as they develop with the secreted fluid in the wound and create a moist wound environment.

   • Secreting ulcers: Wound dressings with high resorption capacity such as foam dressings (Allevyn, Cutinova Foam) or alginates. A good alternative to this is VAC (vacuum) therapy, a moist wound treatment under continuous vacuum. The available study results do not yet allow a definitive overall assessment of the procedure (see VAC below). Methacrylates in Nanoflex technology are also suitable here (e.g. altraZeal).

   • Germ reduction: Wound dressings with elemental silver (e.g. Actisorb, Acticoat, Aquacel Ag) have a good antiseptic effect. Activated charcoal is also used to reduce odor in heavily exuding wounds. Alternatively, cadexomer iodine, polyvidon iodine, octenidine or polihexanide can be used.

3. Epithelialization:

   • Conservative: In most cases, the preparations not only promote granulation but also epithelialization. Hydrocolloid film dressings, hyaluronic acid dressings (Hyalofill F), plastic pads/foam dressings such as (e.g. Mepilex, Cutinova) and fatty gauze (e.g. Oleo-Tuell or Jelonet) are used.

     • Zinc: Checking the zinc level is recommended for long-lasting healing processes. If necessary, zinc supplementation with zinc sulphate (e.g. Zinkit 20) once 1 dr/day p.o. with weekly monitoring of the serum zinc level (normal 80-120 μg/dl) and the zinc excretion in 24-hour urine (normal 200-500 μg/24 hours).

     • Growth factors: The local application of various growth factors has so far been reserved for experimental studies, but has shown healing-promoting effects.

     • Antibiotic treatment: In case of clinical signs of inflammation (redness, hyperthermia, swelling of the wound bed, increased exudation, pain), especially with progressive signs of inflammation, smear and antibiotic treatment after antibiogram.

   • Surgical: In the absence of epithelialization, split-thickness skin grafting or mesh graft plastic surgery may be considered as an alternative. Prerequisites are a clean wound bed, elimination of venous stasis in venous ulcers and, if necessary, excision of the sclerotic ulcer bed. The transplantation of autologous and/or heterologous keratinocytes is also an option. In the case of large and/or deep wound defects or excessively long wound healing, primary surgical wound treatment with necrectomy, resection and subsequent plastic defect coverage may be necessary (full-thickness flap plasty/reverted skin plasty, musculocutaneous flap plasty, etc.).

Phytotherapy:

The phytotherapeutic indication can be used as monotherapy for minor wound problems. The following phytotherapeutics are suitable for this purpose:

Chamomile extracts (Matricaria recutita)

Marigold extracts (Calendula officinalis)

St. John's wort extracts (Hypericum perforatum)

Witch hazel extracts (Hamamelis virginiana)

Bee honey, e.g. Manuka honey

Equiseti herba

s.a. Aloe barbadensis

Callunae flos

Malvae folium

Melaleuca alternifolia

Millefolii flos

Verbasci flos

see also Cod liver oil

Billing information:

Item 5 GOÄ: This item is in the singular and can only be charged once per session. If several examinations are carried out in one session (e.g. in the case of multiple chronic wounds on both legs), an increase in the factor may be justifiable.

Item 2006 GOÄ: This item can be charged per wound. An increase in the factor may be justified in the case of an "oversized extension, very deep wounds or superinfected wounds. An increase in the number could also be justified by the application or change of a wound pad.

Item 204 GOÄ: This item can only be charged once per leg. In the case of an extensive compression bandage, this code can be increased (justification: very complex compression bandage)

Digit 200 GOÄ: This digit can be billed together with digit GOÄ 204 (also multiple times).

Item 34 GOÄ: This item can be used for an "initial consultation involving complex and extensive preliminary findings", or for "complex advice on therapy optimization" or advice on "medication change problems".

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2. GOÄ-Tipp (2015) Billing with higher factors for wound care. Vasomed 27: 204
3. Grotewohl JH (1993) Phase-adapted therapy of ulcus cruris using a hydrogel wound dressing. 7: 3-10
4. Hagedorn M et al. (1995) In-vitro and in-vivo studies on local disinfection and wound healing Hautarzt 46: 319-324
5. Karlsmark T et al. (2003) Clinical performance of a new silver dressing, Contreet Foam, for chronic exuding venous leg ulcers. J Wound Care 12: 351-354
6. Kraft E (2015) Phytotherapy in wound healing. Vasomed 27: 177-178
7. Lehnen M et al. (2006) Contact sensitization of patients with chronic wounds. Dermatologist 57: 303-308
8. Moll I et al. (1995) Application of keratinocytes in the therapy of ulcera crurum. Dermatologist 46: 548-552
9. Peinemann F et al. (2011) Vacuum therapy of wounds. Dtsch Ärztebl 108:381-389
10. Phillips TJ et al (1991) Leg ulcers. J Am Acad Dermatol 25: 965-987
11. Schmidt K et al. (1996) Therapy of leg ulcers with synthetic wound dressings Z Hautkr 71: 254-259
12. Vranckx JJ et al. (2002) Wet wound healing. Plast Reconstr Surg 110: 1680-1687
13. Weinberg JM et al. (2003) Cutaneous infections in the elderly: diagnosis and management. Dermatol Ther 16: 195-205
14. Kapoor N et al. (2021) Manuka honey: A promising wound dressing material for the chronic nonhealing discharging wounds: A retrospective study. Natl J Maxillofac Surg.12(2):233-237. doi: 10.4103/njms.NJMS_154_20. Epub 2021 Jul 15. PMID: 34483582; PMCID: PMC8386265.

Clinic and therapy of wounds

Promotion of wound healing

Wound treatment options with interactive/bioactive wound dressings

Function of various wound dressings